Health inspection·November 21, 2025

F 0686 Level of Harm - Actual harm Residents Affected - Few mobility, required substantial/maximal assistance with upper dressing and personal hygiene, dependent with lower body dressing, bed mobility, and toileting. A review of the resident's plan of care initiated on August 15, 2025, and revised August 28, 2025, indicated assistance was required performing ADLs (activities of daily living) due to a right femur fracture. Interventions and tasks initiated to address ADL deficits included weight bearing right lower extremity immobilizer (is a brace or support device designed to keep the leg straight and restrict knee movement) at all times. The care plan also identified risk for impaired skin integrity due to decreased mobility and directed staff to implement preventative interventions including a low air loss mattress, treatment of any injury per facility protocol, and identification and documentation of any causative factors. A review of a nursing progress note completed by the Director of Nursing (DON) on August 16, 2025, at 1:09 PM documented that the brace on Resident 55's right lower leg was very loose. The DON noted she was able to easily place her hand inside both the top and bottom of the brace even when it was fully tightened. A smaller brace of the same type was obtained from therapy and applied to provide improved support to the resident's distal femur fracture. A review of the facility's investigative documentation for an injury of unknown cause, completed by Employee 1, Registered Nurse, on September 6, 2025, at 5:30 PM revealed that staff discovered a new open area slightly beneath the brace on the resident's right calf during evening care. The RN documented that it was unknown at the time whether the area was pressure-related or vascular in nature and indicated wound care would further assess the area. Resident 55 stated, It hurts when you touch it. Further review of the investigative documentation revealed that Employee 1 reported the immediate actions taken by the facility after the new wound was discovered. The physician and the resident's responsible party (RP) were notified, and the wound was cleansed with normal saline solution (NSS). Xeroform, which is a medicated dressing used to protect wounds from infection and support healing, was applied along with an abdominal pad (ABD). Employee 1 documented these interventions were completed to the best of her ability until a physician order could be obtained to remove the brace or until further wound care orders were issued. The physician also ordered Cephalexin 500 mg twice daily for seven days. Cephalexin is an antibiotic that prevents the growth of bacteria and is commonly prescribed for infections such as pneumonia, ear infections, skin infections, urinary tract infections (UTIs), and bone infections. It was ordered prophylactically, meaning it was prescribed to prevent infection or stop a suspected infection from worsening. A review of the clinical record revealed a nursing progress note completed by Employee 1 on September 6, 2025, at 6:16 PM, which further described the newly discovered open area on Resident 55's right calf. Employee 1 documented the wound was located on the rear aspect of the right lower leg and measured 7.0 centimeters (cm) in length by 8.0 cm in width by 0.8 cm in depth. The nurse recorded N/A (not applicable) for the wound stage. The note described a rancid odor and drainage, with infection suspected based on the color and characteristics of the discharge. Employee 1 documented the wound would require wound care follow-up. A review of Resident 55's physician orders dated September 6, 2025, at 5:58 PM directed staff to cleanse the right calf with NSS, apply Xeroform, and cover the site with an ABD dressing once daily and as needed (PRN) for excessive drainage, soiling, or dressing dislodgement. The physician also ordered an appointment with an outside wound care specialist on September 8, 2025, at 2:30 PM for evaluation of the pressure ulcer. A review of the September 2025 Treatment Administration Report (TAR), which serves as the legal medical record for documenting the administration of prescribed treatments, revealed no evidence that licensed nursing staff completed the ordered wound treatments on September 7, 2025. Additionally, a review of a nurse's progress note completed by Employee 2, a Licensed Practical Nurse (LPN), on September 8, 2025, at 1:58 PM documented that the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395936 If continuation sheet Page 2 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395936 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wayne Woodlands Manor 37 Woodlands Drive Waymart, PA 18472 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Actual harm Residents Affected - Few scheduled wound care specialist appointment for that date was cancelled. A review of the wound assessment completed by the contracted Certified Registered Nurse Practitioner (CRNP) on September 11, 2025, five days after the wound was discovered, identified an in-house acquired Stage III pressure ulcer/injury. A Stage III pressure ulcer is characterized by full-thickness skin loss in which the wound extends into the fatty tissue below the skin. The wound measured 3.0 cm in length by 1.50 cm (centimeters) width, and 0.20 cm in depth. The wound contained 80 percent granulation tissue (new healing tissue) and 20 percent slough (dead tissue requiring removal), with light serosanguineous drainage (thin, blood-tinged fluid). There was no odor after being cleansed. The facility could not provide documented evidence that the newly discovered wound that was found on September 6, 2025, was thoroughly assessed or staged by nursing staff prior to the CRNP's assessment on September 11, 2025. A review of Resident 55's hospital record revealed a wound consultant progress note dated August 13, 2025, at 1:09 PM. The note documented that the resident was non-weightbearing due to a right distal femur fracture and had severe vascular disease of the lower extremities with a history of vascular ulcers. However, the wound care consultant documented that no wounds were present on either lower extremity at the time of the assessment, and that the resident's skin was intact. The record further indicated that prior to discharge from the hospital, a knee immobilizer was in place, and the legs were wrapped as prescribed. During an interview with Employee 3, the facility's Director of Physical Therapy, on November 20, 2025, at 10:17 AM she reported that the knee immobilizer applied to Resident 55's right leg at admission was too large. She stated that physical therapy provided a smaller immobilizer; however, no physical therapy assessment was completed prior to issuing the smaller device, despite the change in equipment. Employee 3 also confirmed that the resident's plan of care required the resident to remain non-weight bearing on the right lower extremity and to wear the immobilizer at all times. The facility could not provide any documented evidence that physician orders were obtained at the time of admission for the use of a knee immobilizer, despite the resident arriving from the hospital with one in place. The facility also could not provide documentation that staff routinely monitored the skin beneath the immobilizer to detect early signs of pressure or irritation. During an interview with the Director of Nursing (DON) on November 20, 2025, at 12:30 PM the above information was reviewed. The DON confirmed that no additional documentation could be provided to demonstrate the facility had effective measures in place to prevent the development of Resident 55's Stage III pressure ulcer. A review of Resident 49's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included multiple sclerosis (a chronic, typically progressive disease involving damage to the sheaths of nerve cells in the brain and spinal cord, whose symptoms may include numbness, impairment of speech and of muscular coordination, blurred vision, and severe fatigue) and dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain.) A review of the resident's readmission evaluation dated May 30, 2025, at 8:43PM revealed the resident was observed with skin impairments that included a pressure area of the left buttock, and other skin impairments that included bruising. The clinical record revealed no additional skin assessments were documented after May 30, 2025. A review of Resident 49's progress notes revealed an entry dated November 17, 2025, at 11:35 AM written by Employee 1, Registered Nurse Supervisor (RN). The progress note documented Resident 49 was observed to have a skin area on the right buttock that was pressure in nature. The progress note further recommended utilizing pressure reduction items, and for staff to follow a turning and repositioning schedule despite these interventions already being in place. A review of a wound observation documented by (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395936 If continuation sheet Page 3 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395936 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wayne Woodlands Manor 37 Woodlands Drive Waymart, PA 18472 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Employee 1 on November 17, 2025, at 11:35 AM revealed a pressure area located on the right buttock measuring 1 cm x 1 cm. However, the documentation did not include a complete wound assessment. Missing elements included depth, surface area calculations, wound characteristics, and staging, as required by facility policy. An observation of Resident 49's wound was conducted with the facility's contracted wound care specialist CRNP (Certified Registered Nurse Practitioner) on November 20, 2025, at 10:30 AM (three days after identification of the wound). The CRNP's assessment identified the wound as a Stage II pressure ulcer/injury. A Stage II pressure ulcer is defined as partial-thickness loss of skin presenting as a shallow open wound with a red or pink wound bed. The wound measured 0.3 cm in length by 0.6 cm in width by 0.1 cm in depth. The facility was unable to provide documentation that a timely and thorough assessment of the pressure ulcer was completed by a Registered Nurse upon identification, including proper staging and a detailed description of the wound. The facility also could not provide the witness statements required by its policy from staff caring for the resident within 24 hours of the wound's identification. During an interview with the Director of Nursing (DON) on November 20, 2025, at 1:00 PM the above findings were reviewed. The DON confirmed no additional documentation could be provided to demonstrate the facility completed a timely and thorough wound assessment for Resident 49. 8 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services. Event ID: Facility ID: 395936 If continuation sheet Page 4 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395936 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wayne Woodlands Manor 37 Woodlands Drive Waymart, PA 18472 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records, facility policy, and staff interviews, it was determined the facility failed to develop and implement an individualized pain management program consistent with professional standards of practice, failed to attempt non-pharmacological interventions to alleviate pain prior to the administration of pain medication prescribed on an as needed basis, and failed to follow physician orders when administering pain medication for two residents out of 20 residents reviewed (Resident 74 and Resident CR1).Findings include: According to the US Department of Health and Human Services, Interagency Task Force, Executive Summary Draft Final Report May 6, 2021, for Pain Management Best Practices, the development of an effective pain treatment plan after proper evaluation to establish a diagnosis with measurable outcomes that focus on improvements including quality of life (QOL), improved functionality, and Activities of Daily Living (ADLs). Achieving excellence in acute and chronic pain care depends on the following: An emphasis on an individualized patient-centered approach for diagnosis and treatment of pain is essential to establishing a therapeutic alliance between patient and clinician. Acute pain can be caused by a variety of different conditions such as trauma, burn, musculoskeletal injury, neural injury, as well as pain due to surgery/procedures in the perioperative period. A multi-modal approach that includes medications, nerve blocks, physical therapy and other modalities should be considered for acute pain conditions. A multidisciplinary approach for chronic pain across various disciplines, utilizing one or more treatment modalities, is encouraged when clinically indicated to improve outcomes. A review of the facility policy labeled Pain Management last reviewed by the facility in January 2025, revealed the facility will recognize when a resident is experiencing pain, identify circumstances when pain can be anticipated, evaluate the existing cause of pain, and manage and prevent pain for residents. A clinical record review revealed Resident 74 was admitted to the facility on [DATE], with diagnoses that included spinal stenosis (abnormal narrowing of the spinal canal that results in pressure on the spinal cord or nerve roots) and unspecified open wound, of the lower left leg. An admission MDS assessment (Minimum Data Set, a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated September 16, 2025, indicated the resident was cognitively intact, with a BIMS score of 14 ( Brief Interview for Mental Status a tool to assess the residents attention, orientation and ability to register and recall new information , a score of 13 to 15 indicates intact cognition). A physician's order dated December 19, 2022, directed staff to administer Resident 74 Acetaminophen 325 mg, give two tablets by mouth four times a day for primary general osteoarthritis (occurs when the cartilage that cushions the ends of the bones in the joints deteriorates causing pain). A physician's order dated March 20, 2025, directed staff to administer Acetaminophen 325 mg, one tablet every twenty-two hours as needed for pain that is mild on a pain scale rated 1 to 3. A pain scale involves the use of numbers to rate pain intensity, most often from 0 to 10, where 0 corresponds to no pain and 10 corresponds to the worst possible pain. Mild pain is typically rated 1 to 3, moderate pain 4 to 6, and severe pain 7 to 10. The March 20, 2025, order also directed that non-pharmacological interventions be attempted prior to administration, including back rub, repositioning, applying ice, turning the lights out, and one-to-one interaction, and further specified that the resident may only have one tablet in twenty-four hours due to a separate scheduled order not to exceed 3 grams in twenty-four hours. A physician's order dated July 30, 2025: Tramadol HCL 25 mg (a Schedule IV narcotic pain medication) every six hours as needed for severe pain rated 7-10. A pain scale is a tool that assigns a number from 0 ( no pain) to 10 ( worst possible pain) to measure pain intensity. Mild pain is typically 1-3, moderate pain 4-6, and severe pain Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395936 If continuation sheet Page 5 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395936 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wayne Woodlands Manor 37 Woodlands Drive Waymart, PA 18472 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 7-10. August 16, 2025: Tramadol HCL 50 mg every six hours as needed for moderate pain. A review of the August 2025 MAR (medication administration record) documented the following:Acetaminophen 325 mg, one tablet every twenty-two hours as needed for mild pain, was administered one time.Tramadol 25 mg was administered six times from August 1 through August 13, 2025. Four of these administrations were outside the physician-ordered pain-rating parameters, meaning the narcotic was not administered in accordance with the provider's instructions for pain rating.Medication administrations outside of ordered parameters included:August 5, 2025, at 9:45 AM: Tramadol given for a reported pain rating of 3 (severe pain order required 7-10).August 9, 2025, at 8:48 AM: Tramadol given for a pain rating of 4.August 10, 2025, at 8:51 AM: Tramadol given for a pain rating of 4.August 12, 2025, at 11:36 AM: Tramadol given for a pain rating of 4. A review of associated documentation revealed no evidence that non-pharmacological interventions were attempted before medication administration, despite orders to attempt interventions such as repositioning, back rub, ice application, reducing stimulation, or one-to-one interaction. Non-pharmacological interventions are methods used to decrease pain without medication, such as changing position, relaxation techniques, heat or cold, or distraction activities. Further clinical record review revealed no documentation explaining the clinical reasoning for selecting a narcotic pain medication when the resident's reported pain level did not meet the provider's parameters.A review of MARs from August 13 through August 31, 2025, revealed Acetaminophen 325 mg was not administered at all during this period. A separate physician's order dated August 16,2025, directed staff to administer Tramadol HCL oral tablet 50 mg (Tramadol is a schedule IV opiate narcotic medication; schedule IV drugs have low potential for abuse) one tablet every six hours as needed for moderate pain. A review of August 13, 2025, through August 31, 2025, MAR revealed that Tylenol 325 mg was not administered to Resident 74. during this period. On August 30, 2025, at 11:05 AM staff administer narcotic pain medication for a pain rating of 3 regardless of a physician's order to give one tablet every 6 hours for moderate pain. Continued review of the clinical record revealed there was no documentation explaining the clinical reasoning for choosing a narcotic pain medication instead of the non-narcotic option when the resident ' s reported pain level did not match the physician's parameters. A review of August 13, 2025, through August 31, 2025, MAR revealed that Tramadol 50 mg was administered seven times. A review of the Controlled Substance Log revealed staff gave an incorrect dose of Tramadol HCL oral tablet 25 mg on five of those administrations On August 20,2025, at 8:49 AM staff administered Tramadol HCL oral tablet 25 mg when the physician's order was for Tramadol HCL 50 mg. On August 21,2025 at 7:44 AM staff administered Tramadol HCL oral tablet 25 mg when the physician's order was for Tramadol HCL 50 mg. On August 24,2025 at 11:56 AM staff administered Tramadol HCL oral tablet 25 mg when the physician's order was for Tramadol HCL 50 mg. On August 24,2025 at 7:51 PM staff administered Tramadol HCL oral tablet 25 mg when the physician's order was for Tramadol HCL 50 mg. On August 25,2025 at 10:27 AM staff administered Tramadol HCL oral tablet 25 mg when the physician's order was for Tramadol HCL 50 mg. On August 27,2025 at 12:02 PM staff administered Tramadol HCL oral tablet 25 mg when the physician's order was for Tramadol HCL 50 mg. An interview was conducted on November 21, 2025, at 12:30 PM with the Director of Nursing (DON), to review the above findings related to the facility's failure to attempt non-pharmacological interventions, failed to follow physician orders when administering pain medication and failed to ensure that pain management is provided to residents consistently with professional standards of practice. A review of CR 1's record revealed the resident was admitted to the facility on [DATE], with diagnoses to include chronic obstructive pulmonary disorder (a condition caused by damage to the airways or other parts of the lung) and muscle weakness. A physician order for August 2025 directed staff to administer (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395936 If continuation sheet Page 6 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395936 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wayne Woodlands Manor 37 Woodlands Drive Waymart, PA 18472 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Hydrocodone/Acetaminophen 5/325 mg (a narcotic pain medication) one tablet every six hours as needed for pain rated 1-5 on the pain scale. A review of CR1's August 2025 MAR revealed repeated administration of the narcotic medication outside the provider's parameters from August 1 through August 30, 2025. Medication was administered for pain ratings ranging from 6 to 10, although the order specified use for pain rated 1-5. The MAR documented more than 40 separate administrations outside the ordered parameters. August 1, 2025, at 09:36AM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale of 7 despite the provider order indication it is it be administered for a scale of 1-5. August 1, 2025, at 4:37PMHydrocodone/Acetaminophen 5/325mg was administered for a pain scale of 10 despite the provider order for the medication to be administered for a scale of 1-5. August 2, 2025, at 04:39AMHydrocodone/Acetaminophen 5/325mg was administered for a pain scale of 6 despite the provider order. August 2, 2025, at 8:14PM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale of 7 despite the provider order. August 3, 2025, at 02:35AM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale of 6 despite the provider's order. August 3, 2025, at 09:48AMHydrocodone/Acetaminophen 5/325mg was administered for a pain scale of 8 despite the provider order. August 3, 2025, at 4:30PM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale of 8 despite the provider order. August 4, 2025, at 8:17PM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 7 despite the provider order. August 5, 2025, at 03:18AMHydrocodone/Acetaminophen 5/325mg was administered for a pain scale 9 despite the provider's order. August 5, 2025, at 10:16AM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 9 despite the provider order. August 5, 2025, at 09:00PM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale of 8 despite the provider order. August 6, 2025, at 03:07AMHydrocodone/Acetaminophen 5/325mg was administered for a pain scale 8 despite the provider order. August 6, 2025, at 09:23AM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 8 despite the provider's order. August 6, 2025, at 7:34PM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 8 despite the provider order. August 7, 2025, at 08:45AMHydrocodone/Acetaminophen 5/325mg was administered for a pain scale 7 despite the provider order. August 8, 2025, at 5:15PM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 9 despite the provider order. August 9, 2025, at 08:03AM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 7 despite the provider order. August 9, 2025, at 3:41PMHydrocodone/Acetaminophen 5/325mg was administered for a pain scale 7 despite the provider order. August 10, 2025, at 8:17AM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 8 despite the provider order. August 11, 2025, at 09:10AM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 8 despite the provider order. August 12, 2025, at 10:06AMHydrocodone/Acetaminophen 5/325mg was administered for a pain scale 7 despite the provider order. August 13, 2025, at 07:53AM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 8 despite the provider order.August 14, 2025, at 3:40PM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 7 despite the provider order. August 15, 2025, at 09:33AMHydrocodone/Acetaminophen 5/325mg was administered for a pain scale 6 despite the provider order. August 16, 2025, at 02:07AM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 10 despite the provider order. August 16, 2025, at 4:28PM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 6 despite the provider order. August 18, 2025, at 11:55PMHydrocodone/Acetaminophen 5/325mg was administered for a pain scale 9 despite the provider order. August 19, 2025, at 09:00AM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 7 despite the provider's order. August 20, 2025, at 09:06AM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 7 despite the provider order. August 20, 2025, at 8:26PMHydrocodone/Acetaminophen 5/325mg was administered (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395936 If continuation sheet Page 7 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395936 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wayne Woodlands Manor 37 Woodlands Drive Waymart, PA 18472 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few for a pain scale 7 despite the provider order. August 21, 2025, at 03:32AM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 7 despite the provider order. August 21, 2025, at 09:38AMHydrocodone/Acetaminophen 5/325mg was administered for a pain scale 8 despite the provider order. August 21, 2025, at 5:42PM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 8 despite the provider order. August 22, 2025, at 01:07AM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 9 despite the provider order. August 22, 2025, at 3:14pmHydrocodone/Acetaminophen 5/325mg was administered for a pain scale 6 despite the provider order. August 23, 2025, at 05:26AM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 9 despite the provider order. August 23, 2025, at 1:21PM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 6 despite the provider order. August 25, 2025, at 09:52AMHydrocodone/Acetaminophen 5/325mg was administered for a pain scale 7 despite the provider's order. August 25, 2025, at 5:59PM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 7 despite the provider order. August 25, 2025, at 11:40PM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 10 despite the provider's order. August 26,2025, at 06:29AMHydrocodone/Acetaminophen 5/325mg was administered for a pain scale 8 despite the provider order. August 26, 2025, at 6:53PM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 8 despite the provider order. August 27, 2025, at 01:44AM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 7 despite the provider order. August 27, 2025, at 8:01PMHydrocodone/Acetaminophen 5/325mg was administered for a pain scale 8 despite the provider order. August 28, 2025, at 04:12AM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 8 despite the provider order. August 30, 2025, at 7:21PM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 7 despite the provider order. A review of CR1's September 2025 MAR revealed medication was again administered outside the physician's ordered parameters on multiple occasions from September 1 through September 17, 2025, with pain scores recorded between 6 and 10.September 1, 2025, at 1:57PM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 7 despite the provider order. September 1, 2025, at 8:05PM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 8 despite the provider order. September 2, 2025, at 03:22AMHydrocodone/Acetaminophen 5/325mg was administered for a pain scale 8 despite the provider order. September 2, 2025, at 10:19AM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 8 despite the provider order. September 2, 2025, at 7:53PM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 7 despite the provider order. September 3, 2025, at 05:24AMHydrocodone/Acetaminophen 5/325mg was administered for a pain scale 8 despite the provider order. September 3, 2025, at 12:30PM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 7 despite the provider order. September 4, 2025, at 05:35AM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 7 despite the provider's order. September 4, 2025, at 1:20PMHydrocodone/Acetaminophen 5/325mg was administered for a pain scale 7 despite the provider order. September 5, 2025, at 04:44AM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 9 despite the provider order. September 5, 2025, at 11:20AM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 7 despite the provider order. September 6, 2025, at 1:33PMHydrocodone/Acetaminophen 5/325mg was administered for a pain scale 9 despite the provider order. September 7, 2025, at 04:47AM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 9 despite the provider order. September 8, 2025, at 07:41AM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 7 despite the provider order. September 8, 2025, at 7:51PMHydrocodone/Acetaminophen 5/325mg was administered for a pain scale 8 despite the provider's order. September 9, 2025, at 08:13AM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 8 despite the provider order. September 9, 2025, at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395936 If continuation sheet Page 8 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395936 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wayne Woodlands Manor 37 Woodlands Drive Waymart, PA 18472 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 8:14PM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 7 despite the provider order. September 10, 2025, at 5:18PM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 7 despite the provider's order. September 12, 2025, at 08:44AM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 7 despite the provider order. September 13, 2025, at 08:17AMHydrocodone/Acetaminophen 5/325mg was administered for a pain scale 7 despite the provider order. September 14, 2025, at 06:39AM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 6 despite the provider order. September 14, 2025, at 7:10PM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 9 despite the provider order. September 15, 2025, at 05:49AMHydrocodone/Acetaminophen 5/325mg was administered for a pain scale 6 despite the provider order. September 15, 2025, at 8:20PM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 7 despite the provider order. September 16, 2025, at 10:19AM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 7 despite the provider order. September 16, 2025, at 7:51PMHydrocodone/Acetaminophen 5/325mg was administered for a pain scale 7 despite the provider order. September 17, 2025, at 02:37AM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 7 despite the provider order. September 17, 2025, at 08:54AM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 7 despite the provider order. September 17, 2025, at 4:31PMHydrocodone/Acetaminophen 5/325mg was administered for a pain scale 8 despite the provider order. The clinical record did not contain documentation explaining clinical reasoning for these administrations when the pain levels did not meet the ordered parameters.An interview was conducted on November 21, 2025, at 12:35 PM with the Director of Nursing to review the findings related to CR1. 28 Pa. Code 211.10(d) Resident care policies.28 Pa Code 211.12 (d)(3)(5) Nursing Services. Event ID: Facility ID: 395936 If continuation sheet Page 9 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395936 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wayne Woodlands Manor 37 Woodlands Drive Waymart, PA 18472 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0744 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, review of facility-provided investigative documentation, care plan review, and facility staff interview, it was determined that the facility failed to develop and implement an individualized, person-centered plan of care to address dementia-related behaviors for one resident (Resident 31) out of a sample of 20 residents reviewed. Findings include:A review of Resident 31's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses which included dementia (a chronic or persistent disorder of mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning).A review of Resident 31's Annual Minimum Data Set Assessment (MDS, a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated September 22, 2025, revealed the resident was severely cognitively impaired.A review of nursing progress notes between July 2025 and the end of survey on November 21, 2025, revealed Resident 31 demonstrated ongoing behavioral symptoms including physical and verbal aggression toward residents and staff, intrusive wandering (entering others' rooms or personal spaces without understanding boundaries), and resistance to care. Documentation showed that intrusive wandering occurred almost daily during this period.Further review of Resident 31's facility provided investigative documentation revealed the following:On July 23, 2025, staff heard yelling from a resident room. Upon entering, staff observed Resident 31 slap Resident 25. The residents were separated, and no injury was noted. Resident 31 and Resident 25 were roommates at that time, and Resident 31 was subsequently moved to a private room.On July 26, 2025, staff found Resident 31 in Resident 93's room. Resident 31 slapped Resident 93 and poured water on her. The residents were separated, and no injury was noted.On September 13, 2025, while staff were walking with Resident 31 in the hallway, the resident wandered into Resident 51's room and grabbed at Resident 51's arm. Residents were separated and no injury was noted.A review of the Resident 31's current care plan initially dated July 13, 2025, and last revised August 26, 2025, revealed no new interventions added in response to the repeated incidents of physically aggressive behaviors, intrusive wandering, and resistance to care. Further review revealed no documented evidence that the facility developed an individualized, person-centered dementia care plan, which would include approaches intended to support the resident's dignity, autonomy, safety, socialization, and daily functioning. A person-centered dementia care plan includes individualized, non-pharmacological interventions (non-medication-based actions such as structured activities, environmental modifications, redirection, music therapy, sensory activities, or schedules tailored to a resident's preferences) designed to address the resident's customary routines, past life history, interests, and behavioral triggers. There was no documented evidence that the facility identified or implemented individualized strategies to manage, modify, or decrease the resident's ongoing dementia-related behaviors despite multiple documented behavioral incidents. An interview with the Nursing Home Administrator on November 21, 2025, at 10:00 AM, confirmed that the facility was unable to provide evidence that an individualized, person-centered plan of care had been developed or implemented to address Resident 31's dementia-related behavioral symptoms 28 Pa Code 211.12 (d)(3)(5) Nursing services Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395936 If continuation sheet Page 10 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395936 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wayne Woodlands Manor 37 Woodlands Drive Waymart, PA 18472 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, select facility policy, observation, and staff interview, it was determined that the facility failed to implement effective procedures to maintain accurate records of controlled drugs and ensure accurate drug administration for one resident out of 20 sampled (Resident 74). Findings include: A facility policy titled Controlled Substances last reviewed by the facility on January 2025, revealed that during medication administration, the facility shall comply with all laws regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II narcotics (pain medications that have a high potential for abuse and require strict documentation). The Director of Nursing and/or designee will audit narcotics received using the signed invoices and a printout of all narcotics dispensed from the pharmacy on a periodic basis to identify potential signs of diversion. A clinical record review revealed Resident 74 was admitted to the facility on [DATE], with diagnoses that include spinal stenosis (abnormal narrowing of the spinal canal that results in pressure on the spinal cord or nerve roots) and unspecified open wound of the lower left leg. A review of the clinical record revealed a physician's order dated July 30, 2025, for Tramadol HCL 25 mg, an oral Schedule IV controlled substance (have a lower potential for abuse but still require secure handling and accurate record-keeping), one tablet every six hours as needed for severe pain rated seven to ten (a pain scale involves the use of numbers to rate pain intensity, most often from 0 to 10, where 0 corresponds to no pain and 10 corresponds to the worst possible pain. Mild pain is typically rated 1 to 3, moderate pain 4 to 6, and severe pain 7 to 10), for 14 days. A review of facility clinical records revealed the facility utilizes a Controlled Substance Record to track, monitor, and reconcile each controlled medication, such as Tramadol and Oxycodone. Further review of facility clinical records revealed the facility tracks medication administration for each resident by way of the Medication Administration Record (MAR). The MAR indicates the medication administered, time and date of administration, staff administering the medication, pain prior to the administration of medication, and clinical rationale for the administration of medication.A comparison of Resident 74's Controlled Substance Record with the MAR from August 8 through August 30, 2025, revealed 10 entries showing Tramadol 25 mg signed out on the Controlled Substance Record without corresponding documentation on the MAR indicating that the medication was administered. The following is a list of the dates where there is a discrepancy in Resident 74's Controlled Substance Record and the MAR: August 8, 2025, at 8:30 AMAugust 13, 2025, at 7:30 AMAugust 15, 2025, at 8:00 AMAugust 18, 2025, at 12:00 PMAugust 19, 2025, at 8:30 AMAugust 22, 2025, at 12:00 PMAugust 23, 2025, at 11:00 AMAugust 26, 2025, at 12:00 PMAugust 28, 2025, at 7:30 AMAugust 29, 2025, at 1:00 PM Further comparison revealed that on August 12, 2025, Tramadol 25 mg was signed out twice on the Controlled Substance Record (at 8:15 AM and 8:30 AM), while the MAR showed the medication documented as administered once at 11:36 AM.A review of the MAR revealed an additional discrepancy on August 30, 2025: the MAR documented administration at 11:14 AM, but the Controlled Substance Record showed no entry indicating that a dose had been signed out. A physician's order dated August 16, 2025, initiated Tramadol HCL 50 mg, a Schedule IV controlled substance, to be given every six hours as needed for moderate pain.A comparison of the Controlled Substance Record and MAR from September 1 through September 30, 2025, revealed five entries indicating the medication was signed out without evidence on the MAR of administration. The dates included: September 1,2025, at 11:55 AMSeptember 9,2025 at 12:00 PMSeptember 10,2025 at 1:00 PMSeptember 19,2025 at 11:00 AMSeptember 20,2025 at 10:00 AM A comparison from October 1 through October 30, 2025, revealed five additional discrepancies in which Tramadol 50 mg was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395936 If continuation sheet Page 11 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395936 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wayne Woodlands Manor 37 Woodlands Drive Waymart, PA 18472 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete signed out on the Controlled Substance Record without documented administration on the MAR. These dates included: October 3,2025 at 2:20 PMOctober 4,2025 at 1:00 PMOctober 7,2025 at 1:30 PMOctober 10,2025 at 2:00 PM A clinical record review revealed a physician's order dated October 13, 2025, for Oxycodone HCL 5 mg, a Schedule II controlled substance (high potential for abuse), one tablet by mouth every Monday morning for pain related to skin substitute placement (a procedure used to assist healing of wounds such as diabetic foot ulcers and venous leg ulcers).A comparison of the Controlled Substance Record with the MAR from October 1 through November 17, 2025, revealed two entries showing Oxycodone signed out without documentation on the MAR that the medication was administered: October 13,2025 at 7:30 AMNovember 3,2025 at 7:30 AM An interview was conducted on November 20, 2025, at 1:30 PM with the Director of Nursing to review the above findings. The information reviewed during the interview confirmed that the documentation did not reconcile between the Controlled Substance Record and the MAR for Resident 74. 28 Pa Code 211.5(f)(xi) Medical records. 28 Pa Code 211.9(a)(1)(k) Pharmacy services. 28 Pa Code 211.12 (d)(1)(3)(5) Nursing services. 28 Pa Code 211.10 (c)(d) Resident care policies. Event ID: Facility ID: 395936 If continuation sheet Page 12 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395936 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wayne Woodlands Manor 37 Woodlands Drive Waymart, PA 18472 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records, select facility policy and staff interviews, it was determined the facility failed to ensure that a resident's drug regimen was free of unnecessary antibiotics for one out of 20 residents sampled (Resident CR1). Findings included: A review of a facility policy labeled Antibiotic Stewardship Program last reviewed by the facility in January 2025, revealed the facility will confirm the presence of clinical symptoms of infection before collecting cultures or starting antibiotics. The policy revealed the facility will use standardized forms/checklists for urinary tract infections, and the facility will obtain cultures before starting antibiotics whenever feasible. The policy further revealed that a resident will only be started on empiric antibiotics (antibiotic use before laboratory results are available) only if the resident meets clinical criteria and appears systemically ill (fever, tachycardia, hypotension, rigors). A review of Resident CR1's clinical record revealed the resident was admitted on [DATE], with diagnoses including chronic obstructive pulmonary disorder (a lung disease that causes airway damage and breathing difficulty) and muscle weakness. A review of a quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated August 11, 2025, revealed that Resident CR 1 had intact cognition with a BIMS score of 13 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact). Review of resident CR1's progress notes revealed a progress note documented on October 5, 2025, at 1:34 PM indicating the resident's family had expressed concerns about the resident's increased hallucinations (sensory experiences such as seeing, hearing or feeling something that appear real but are not present in the environment), the progress note revealed at the request of the family a urinalysis with culture and sensitivity (a laboratory test used to detect and identify bacteria or fungi in urine, A urine culture is a method to grow and identify bacteria that may be in the urine. The sensitivity test helps select the best medicine to treat the infection) to assess for possible infection) was ordered. Further review of CR1's progress notes revealed a progress note dated October 6, 2025, at 2:52PM documenting that the resident had no signs of a urinary tract infection. A progress note dated October 6, 2025, at 2:52 PM documented that the resident had no signs or symptoms of a urinary tract infection, and the physician was notified of the abnormal urinalysis results while awaiting culture and sensitivity (C&S) results. A progress note dated October 7, 2025, at 11:46 AM revealed the physician was made aware of preliminary urinary culture results and had no new orders at that time. Another progress note dated October 7, 2025, at 2:25 PM again documented that the resident was not experiencing any urinary symptoms, including no confusion. Despite the absence of urinary symptoms, a physician order dated October 8, 2025, directed initiation of Macrobid 100 mg twice daily for 5 days. Macrobid is an antibiotic used to treat urinary tract infections. A review of the urine culture and sensitivity report, resulted on October 9, 2025, at 7:16 AM, revealed the presence of two organisms:Citrobacter werkmanii, a bacterium that can cause urinary tract infections, andProteus mirabilis, a gram-negative bacterium known to cause urinary tract infections.The sensitivity results revealed that Proteus mirabilis was resistant to Macrobid, meaning Macrobid would not effectively treat the infection. A progress note dated October 9, 2025, at 3:22 PM documented that the provider reviewed the culture and sensitivity results and discontinued Macrobid. A new order was entered for Bactrim DS, an antibiotic active against the identified organism, for 10 days. A review of Resident CR1's clinical record revealed that three Urinary Change Forms, documented on October 7, 2025, at 2:38 PM, October 8, 2025, at 10:32 PM, and October Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395936 If continuation sheet Page 13 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395936 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wayne Woodlands Manor 37 Woodlands Drive Waymart, PA 18472 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 9, 2025, at 2:40 PM, all indicated no changes in the resident's condition that would justify initiating Macrobid prior to receiving culture results. A review of the October 2025 Medication Administration Record revealed the resident received two doses of Macrobid before laboratory confirmation of an infection requiring antibiotic therapy and before the organism's resistance to Macrobid was known. The clinical record did not contain any documentation of urinary symptoms that would meet clinical criteria for initiating empiric antibiotic therapy (use of antibiotics before laboratory results are known). The facility was unable to provide documentation of McGeer's criteria, a standardized set of infection surveillance criteria used in long-term care settings to determine when an infection is present. These criteria require documented urinary symptoms to justify antibiotic treatment, and no such symptoms were documented. During an interview with the Director of Nursing (DON) on November 20, 2025, at 1:15 PM, the DON reviewed the clinical findings with the surveyor. The DON acknowledged the documented sequence of events and discussed that the antibiotic had been started before culture confirmation and without documented clinical symptoms. 28 Pa. Code 211.10 (c) Resident care policies.28 Pa. Code 211.12 (d)(3)(5) Nursing services Event ID: Facility ID: 395936 If continuation sheet Page 14 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395936 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wayne Woodlands Manor 37 Woodlands Drive Waymart, PA 18472 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, review of select facility policy and clinical records, and staff interviews, it was determined the facility failed to adhere to acceptable storage and labeling practices for multi-dose medications in one of two medication carts observed (Blue Hall C Unit). Findings include: Review of the facility policy titled Medication Administration last reviewed by the facility January ,2025, indicated that the expiration date/beyond use date on the medication label must be checked prior to the administering. When opening multi-dose container, the date opened shall be recorded on the container. labels are checked prior to administration. A multi-dose medication is a container designed to be used for more than one dose and must be dated when first opened so staff can determine when it expires and whether it is safe to use. Failure to date a multi-dose container prevents staff from knowing the beyond-use date, which is the date after which the medication should no longer be used for resident safety. An observation of the medication cart located on the Blue Hall C Unit on November 20, 2025, at 8:25 AM, in the presence of Employee 4 (Licensed Practical Nurse), revealed two multi-dose insulin pens of Humalog (Insulin Lispro, a rapid-acting insulin used to lower blood sugar) that were opened and available for resident use but were not dated to indicate when they were initially opened.A continued observation of the same medication cart on November 20, 2025, at 8:25 AM, in the presence of Employee 4, revealed two multi-dose insulin pens of Novolog (Insulin Aspart, a fast-acting insulin used to lower blood sugar) that were opened and available for resident use but were not dated when initially opened.A further observation of the medication cart on November 20, 2025, at 8:25 AM, in the presence of Employee 4, revealed one multi-dose insulin pen of Novolog 70/30 (Insulin Aspart Protamine and Insulin Aspart injectable suspension, a combination insulin used to lower blood sugar) that was opened and available for resident use but was not dated when initially opened. An interview with Employee 4 (LPN) on November 20, 2025, at 8:30 AM confirmed that the five multi-dose insulin pens observed (Humalog Insulin Lispro, Novolog Insulin Aspart, and Novolog 70/30 Insulin Aspart Protamine and Insulin Aspart injectable suspension) were opened and available for resident use without any date indicating when they were first opened.An interview was conducted with the Director of Nursing on November 20, 2025, at 11:00 AM regarding the above findings related to the facility's failure to follow acceptable storage and labeling practices for multi-dose medications. 28 Pa. Code 211.9(a)(1)(k) Pharmacy services 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services 28 Pa. Code 211.10(c) Resident Care Policies Event ID: Facility ID: 395936 If continuation sheet Page 15 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395936 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wayne Woodlands Manor 37 Woodlands Drive Waymart, PA 18472 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0773 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, the facility failed to ensure that laboratory and diagnostic test results were promptly provided to the ordering physician for one of twenty sampled residents (Resident CR1).Findings include: A review of resident CR 1's record revealed the resident was admitted to the facility on [DATE], with diagnoses to include chronic obstructive pulmonary disorder (a condition caused by damage to the airways or other parts of the lung) and muscle weakness. A review of a quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated August 11, 2025, revealed that Resident CR 1 had intact cognition with a BIMS score of 13 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact). A nursing progress note dated October 9, 2025, at 8:03 AM documented a phone call from the resident's family reporting the resident was experiencing uncontrolled head and neck pain following a fall within the facility. A cervical spine x-ray (a diagnostic test that uses radiographs to visualize the bones of the neck) was completed on October 9, 2025, at 11:24 AM. The x-ray report identified an apparent right-lung infiltrate, which is an abnormal substance or fluid in lung tissue that can occur for various reasons, including infection. The report recommended clinical correlation and a follow-up chest x-ray. A review of Resident CR1's clinical record revealed no documentation that the physician was notified of the abnormal x-ray findings. The clinical record also revealed no documentation that the recommended follow-up chest x-ray had been completed. During an interview on November 21, 2025, at approximately 12:00 PM, the Director of Nursing (DON) reviewed the above findings with the surveyor. The DON did not provide an explanation for the absence of documentation showing the physician had been notified of the abnormal results or had reviewed the x-ray findings. The DON confirmed that it is the facility's responsibility to ensure the physician is promptly provided with laboratory and diagnostic test results. 28 Pa Code 211.2 (d)(3) Medical director. 28 Pa Code 211.12 (d)(3) Nursing services. Event ID: Facility ID: 395936 If continuation sheet Page 16 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395936 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wayne Woodlands Manor 37 Woodlands Drive Waymart, PA 18472 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. Based on review of scheduled mealtimes, review of select facility policy, resident interviews, and staff interviews, the facility failed to ensure that residents were consistently offered a nutritious evening snack during the time interval between dinner and breakfast, resulting in the potential for more than 14 hours between meals without the required nutritional snack. This deficient practice was identified for 6 of 6 residents participating in a group interview who desired a bedtime snack. (Residents 35, 47, 50, 51, 51, and 75).Findings include: A review of the facility policy titled Snack Policy, last reviewed by the facility in January 2025, revealed it is the facility's policy to offer a safe, consistent, and nutritionally adequate snack three times daily at 10:00 AM, 2:00 PM, and at H.S. (hour of sleep/bedtime). A review of scheduled facility mealtimes revealed that the interval between dinner and breakfast exceeds 14 hours for multiple resident care areas. The substantial evening meal is served between 4:45 PM and 5:25 PM depending on unit, and breakfast is served between 7:10 AM and 7:45 AM the following morning, resulting in time intervals ranging from 14 hours 15 minutes to 15 hours. Blue Hall: Dinner 4:55 PM, Breakfast 7:10 AM (14 hours 15 minutes)Dining Room: Dinner 4:45 PM, Breakfast 7:45 AM (15 hours)Peach Hall: Dinner 5:05 PM, Breakfast 7:20 AM (14 hours 15 minutes)Green Hall: Dinner 5:15 PM, Breakfast 7:30 AM (14 hours 15 minutes)Mauve Hall: Dinner 5:25 PM, Breakfast 7:40 AM (14 hours 15 minutes) When more than 14 hours elapse between the substantial evening meal and breakfast the next day, the resident must be offered a nutritious snack at bedtime. Because the facility's scheduled meal intervals exceeded 14 hours, offering an evening snack was required to ensure residents received adequate food intake during this extended overnight period. During a resident council interview on November 19, 2025, at 10:00 AM, 6 out of six residents (Residents 35, 47, 50, 51, 51, and 75) indicated that a snack is not offered in the evenings. All residents reported that they do not receive a snack before bedtime. During an interview on November 20, 2025, at approximately 2:00 PM, the Nursing Home Administrator was unable to provide documentation showing that evening snacks were consistently offered to residents. 28 Pa. Code 211.12 (d)(3)(5) Nursing services. 28 Pa. Code 211.10 (c) Resident Care Policies. Event ID: Facility ID: 395936 If continuation sheet Page 17 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395936 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wayne Woodlands Manor 37 Woodlands Drive Waymart, PA 18472 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm Based on observation, staff interviews, and review of facility policy, the facility failed to maintain a fully functioning resident call bell system that ensured residents could directly and promptly request assistance from staff for three of four halls in the facility (Green Hall, Mauve Hall, and Blue Hall).Findings include:A review of the facility policy titled Call Light and Procedure last reviewed by the facility in January 2025, revealed it is the responsibility of all staff to respond to call bells, to ensure all resident's requests and needs. The policy revealed it is the responsibility of staff to report all defective call lights to the nurse supervisor promptly and then provide hand bells to residents for use (a manual device used to request help when the main system does not work).An observation conducted on November 17, 2025, at 10:20 AM, revealed that multiple call bell lights were illuminated on three of four halls: four lights on Mauve Hall, five on Blue Hall, and two on [NAME] Hall, as well as one light on Peach Hall. However, there was no audible alert for any of these active call bells. Staff could only detect a resident request for assistance if they visually noticed the small, illuminated light above the resident room door while physically standing in the hallway. The absence of an audible alert prevented staff from being notified promptly when not in direct view of the lights. An interview with Employee 1 on November 18, 2025, at 10:22 AM, revealed the call bell system sometimes activates the sound but not often, and staff identify resident requests only by visually checking the door lights. The interview did not identify any alternate alerting mechanism in use. An interview with the Nursing Home Administrator (NHA) on November 18, 2025, at 11:00 AM, revealed the facility had previously identified the issue with the call bell system and planned to replace the system in 2026. The interview also revealed that although the facility had previously purchased handheld bells for emergencies, residents had not been provided with these or any other alternative method to call for assistance while the system was malfunctioning. After multiple requests during the survey, the facility was unable to provide documentation demonstrating that a work order or repair request had been submitted to address the ongoing malfunction of the call bell system, despite having prior knowledge that it was not functioning as intended.An interview with the NHA on November 19, 2025, at 11:05 AM, acknowledged the findings that the call bell system was not functioning according to the manufacturer's design, which resulted in delayed identification of resident call bell requests. 28 Pa Code 207.2(a) Administrators responsibility 28 Pa Code 205.28 (c)(1)(4) Nurses station 28 Pa Code S211.10 (c)Resident Care Policies Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395936 If continuation sheet Page 18 of 18